Recording and Reporting Charting Recording and Reporting

Recording and Reporting Health care workers must listen carefully AND make observations They use their senses to make certain observations about their patient and report them.

Use your senses to See Smell Color of skin, swelling, edema Presence of rash or sore Color of urine or stool Amount of food eaten Smell Body odor Unusual odors of breath, wounds, urine or stool

Use your senses Touch Hearing Pulse Dryness or temp of skin Perspiration swelling Hearing Respirations Abnormal body sounds Coughs speech

Charting and Reporting Observations should be reported accurately – use facts and report what you say, not the reasons. NOT – Mr. Ruiz is in pain INSTEAD – Mr. Ruiz is moaning and holding his left side. Observations on a patient’s health record should be accurate, concise, and complete.

Charting Objective observations – what was seen. DO NOT record what you feel or think. If a patient’s statement is recorded, use the pt’s own words and quotation marks. Sign entries with name and title of the person recording information. Cross out errors neatly with a straight line, write “error” and initial error.

Subjective Data What you think or feel. May or may not be accurate. Based on assumptions. Not advisable to use on medical charts.

Subjective (continued) Example: Ms. Jones is visiting with family and laughing. She is not in pain right now.

Subjective example……. Ms. Smith has a bad headache.

Objective Data What is actually seen. Only facts documented Best way to document on medical record.

Example Ms. Jones is sitting on couch with family and friends surrounding her, smiling and looking at camera.

Example Ms. Smith has her eyes closed and is holding her forehead with both hands.

Record your observations

Record Your Observation

Record your observations